Tx for Pediatric Acne Gets New Guidance

Action Points

Acne also presents in children and infants, and treatments should be age appropriate, according to new recommendations from the American Acne and Rosacea Society.

Point out that among over-the-counter remedies, benzoyl peroxide appeared to be "somewhat effective" for mild acne and remained the overall go-to treatment, either alone or combined with other therapies.

Typically seen as a teenager's disease, acne also presents in children and infants, and treatments should be age appropriate, according to new recommendations from the American Acne and Rosacea Society.

Although pediatric acne reportedly affects up to 87% of teenagers, a 1994 study found acne in 78% of 365 girls, ages 9 and 10, stated Lawrence Eichenfield, MD, of Rady's Children's Hospital in San Diego, and colleagues in Pediatrics online.

Even babies get acne with 20% of newborns affected, they added.

"It is essential to have a broad understanding of acne at different ages and to be aware of the differential diagnoses for each age group," the authors stated in an evidence-based evaluation of more than 150 dermatology-related studies.

The guidelines, endorsed by the the American Academy of Pediatrics, are segmented based on age:

In neonates, pustules on the face and upper body represent acne or acne-like conditions, and are best treated with 2% ketoconazole cream. Physicians should consider underlying endocrinologic diseases, tumors, or gonadal/ovarian pathology in the presence of significant acne.

In infants to 12 months, acne is predominate in boys. Treatment can include topical antimicrobials, topical retinoids, noncycline antibiotics (erythromycin), and, occasionally, isotretinoin. None of these medications are indicated by the FDA for use in this age group, they cautioned.

In mid-childhood up to 7 years, acne is rare, so an endocrine abnormality should be suspected and investigated. Oral tetracyclines are not an option because of the risk to developing teeth and bones.

In preadolescence, best defined as up to the age of menarche, acne on the T-zone of the face may be the first sign of puberty. With severe acne, polycystic ovary syndrome or other endocrinologic abnormality should be considered, but pelvic ultrasound is not useful in this diagnosis.

Among over-the-counter remedies, benzoyl peroxide appeared to be "somewhat effective" for mild acne and remained the overall go-to treatment, either alone or combined, Eichenfield and colleagues wrote. Salicylic acid was less so, they stated.

Too harsh cleaners can aggravate the condition as children strive to scrub away the acne, the authors stated. However, they pointed out that cosmetics and poor hygiene do not contribute to eruptions, and, make-up may increase patient well-being.

"Antibacterial washes, other than [benzoyl peroxide], have not been shown to be useful in the treatment of acne," the paper stated. "Benzoyl peroxide has been shown to be the most widely studied of [over-the-counter] products and has been shown to be one of the most versatile, safe, inexpensive and effective acne therapies."

Topical retinoids have been proven safe in adolescent patients 12 and older, they stated. Tretinoin gel 0.05% has been FDA-approved for children 10 and older. Adapalene and tazarotene are alternative treatments that also can be used safely.

Topical antibiotics (clindamycin, erythromycin), however, are not recommended as monotherapy because they are too slow to act and likely to develop resistance. Topical benzoyl peroxide should be paired with topical antibiotics in treatments longer than a few weeks, which describes most acne treatment, they wrote.

For moderate acne, oral antibiotics may be added to topical treatments. Used to treat acne for 50 years, oral antibiotics -- except for extended-release minocycline -- are not FDA approved for acne, the authors noted. But commonly prescribed oral antibiotics for children 8 and older are tetracycline, doxycycline, and minocycline.

However, the tetracycline class, including minocycline, should not be taken by children who have not developed permanent teeth.

Another more recent remedy, topical dapsone, a synthetic sulfone, has been shown effective as a microbial and anti-inflammatory, the authors wrote.

For girls with moderate to severe acne, hormonal therapy with combined oral contraceptives "may be useful as second-line therapy," they wrote.

Food, often blamed for acne, may or may not contribute to the disease, although dairy and acne might be associated. A low-glycemic diet in a 12-week study showed "superior reduction in lesions," they noted.

The main issue in younger patients and successful acne treatment is lack of adherence.

"Physicians who see the patient at intervals rather than daily, may note improvement between visits that may not be readily apparent to the adolescent who examines his or her face in the mirror several times daily," they wrote.

Patients often view their acne as being worse than it really is, potentially having an adverse impact on quality of life, the researchers stated. "Emotional symptoms were as severe as those reported by individuals with chronic medical conditions such as chronic asthma, epilepsy, diabetes, and back pain or arthritis," they stated.

All authors ﬁled relevant conﬂicts of interest statements with the American Acne and Rosacea Society (AARS) and the American Academy of Pediatrics. They received compensation from the AARS for participation in this consensus conference.

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